NUR 102 Final Review |ati detailed answer key
1. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the
nurse take?
A. Secure the restraints using a quick-release tie.
Rationale: The nurse should secure the restraints using a quick-...
Detailed Answer Key
NUR 102 Final Review
1. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the
nurse take?
A. Secure the restraints using a quick-release tie.
Rationale: The nurse should secure the restraints using a quick-release tie for easy removal in an
emergency.
B. Ensure four fingers fit under the restraints to prevent constriction.
Rationale: The nurse should prevent constriction by inserting two fingers under the restraints. The restraint
might be ineffective if the nurse can insert four fingers under it.
C. Secure the restraints to the lowest bar of the side rail.
Rationale: The nurse should secure the restraints to an area of the bed frame that moves with the client
when repositioning, such as raising and lowering the head of the bed. The nurse should not
secure the restraints to the side rail.
D. Anticipate removing the restraints every 4 hr.
Rationale: The nurse should remove the restraints at least every 2 hr or more frequently according to
facility policy.
2. A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom
during the night." Which of the following actions should the nurse take?
A. Limit the client's fluid intake in the evening.
Rationale: This is not an appropriate nursing action.
B. Obtain a bedside commode for the client's use.
Rationale: This is not an appropriate nursing action.
C. Leave a nightlight on in the client's room.
Rationale: This is an appropriate action for keeping the client safe. Night vision may be impaired in older
adult clients. If the client awakens in the night, a nightlight may help the client to recognize the
surroundings, decreasing the likelihood of disorientation. It will also help to decrease the
possibility of a fall on the way to the bathroom because the path will be illuminated and the client
will be less likely to trip over objects in the room.
D. Put the side rails up and tell the client to call the nurse before voiding.
Rationale: This is not an appropriate nursing action.
3. A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the
following statements by the AP indicates an understanding of the teaching?lOMoARcPSD|25701531 Detailed Answer Key
NUR 102 Final Review
A. “I will check the patient's skin every day.”
Rationale: This statement by the AP does not indicate an understanding of the teaching. Skin integrity at
the restraint sites should be checked every 2 hours
B. “I check the patients circulation proximal to the restraint every 4 hours”
Rationale: This statement by the AP indicates does not have an understanding of the teaching. Circulation
should be check distal to the restraint every 2 hours.
C. “I will release the restraints every 2 hours and check if the patient needs to go to the bathroom"
Rationale: This statement by the AP does have an understanding of the teaching. Restraints should be
released every 2 hours while monitoring for behaviors and meeting any personal needs the
patient may have like food, drink, repositioning, bathroom needs, mouth care.
D. “As long as the patient is confused, I will leave the restraints on"
Rationale: This statement by the AP does not indicate an understanding of the teaching. Restraints are to
be removed when the patient is no longer exhibiting the behaviors they were ordered for such as
tubbing on their central line, confusion alone is not a reason for restraints. Restraints are last
intervention before trying other techniques to keep patient safe
4. A client receives a wrong medication. The nurse who made the medication error should take which of the following
actions first?
A. Call the client’s provider.
Rationale: The nurse will have to notify the client’s provider in case the client needs medical intervention
and to follow the facility’s protocol for such incidents; however, there is another action the nurse
should take first.
B. Assess the client.
Rationale: The first action the nurse should take using the nursing process is to assess the client. The
nurse must first determine whether or not the error has caused the client any harm and also
provide any relevant interventions.
C. Notify the nurse manager.
Rationale: The nurse will have to notify the nurse manager to follow the facility’s protocol for such incidents;
however, there is another action the nurse should take first.
D. Complete an incident report.
Rationale: The nurse will have to complete an incident report to follow the facility’s protocol for such
incidents and to give risk managers the opportunity to investigate and institute preventive
measures if necessary; however, there is another action the nurse should take first.
5. A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all
that apply.)lOMoARcPSD|25701531 Detailed Answer Key
NUR 102 Final Review
A. Keep the client’s room dark at night.
B. Teach the client to use the call light.
C. Keep the client’s bed in the lowest position.
D. Place a fall-risk identification band on the client’s wrist.
E. Assess the client every 4 hr.
Rationale: Keep the client’s room dark at night is incorrect. The client’s room should have night lights or low
lighting to improve visibility and help prevent falls.Teach the client to use the call light is correct.
Clients need an easy, accessible way to summon assistance, especially those who are at risk
for falls.Keep the client’s bed in the lowest position is correct. With the bed in the lowest position
and the wheels locked, the client is less likely to fall when getting out of bed.Place a fall-risk
identification band on the client’s wrist is correct. Fall-risk bands, usually yellow, help staff
identify clients at risk and take precautions to prevent falls.Assess the client every 4 hr is
incorrect. Nurses should do hourly rounding at night for clients at risk for falls and every 2 hr
during daytime hours.
6. A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods
should the nurse plan to use?
A. One nurse lifting as the client pushes with his feet
Rationale: While the client can assist by pushing with his feet, the nurse needs additional assistance to
prevent injury.
B. Two nurses lifting the client under the shoulders
Rationale: Lifting the client under the shoulders places musculoskeletal strain on the nurses and the client,
and could cause injury.
C. One nurse lifting the client’s legs as the client uses a trapeze bar
Rationale: While the client can assist by using a trapeze bar, the nurse needs additional assistance to
prevent injury.
D. Two nurses using a friction-reducing device
Rationale: This method reduces the risk of injury to the nurses and to the client. The nurses can use a draw
sheet as a friction-reducing device.
7. A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should
the nurse identify as an indication that the client understands the instructions?
A. “I will keep my walker at the end of my bed.”
Rationale: The client should keep her walker at the side of the bed to be available when she awakens.
B. “I will keep the fluorescent ceiling light on in my room at night.”
Rationale:lOMoARcPSD|25701531
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